[Add School District Name] - Oregon



[Add School District Name]SHARING FREE OR REDUCED PRICE INFORMATIONWITH OTHER PROGRAMSDear Parent/Guardian:The information you give on the Confidential Application for Free or Reduced Price Meal is only used to determine your student(s) eligibility for Free or Reduced Price meals. The information may also be used to determine your student(s) eligibility to receive benefits for other programs. For the following programs we must have your permission to share your information.Sending in this form will not change whether your student(s) get free or reduced meals.Signing this waiver is NOT A REQUIREMENT for participation in any school nutrition program.___ No! I DO NOT want information from my Free and Reduced Price School Meals Application shared with any of the programs listed below.If you checked “No”, stop here. You do not have to complete or send in this form. Your information will not be shared.___ Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with: (Mark each program to which you want information released.)___ [Name of specific program]___ [Name of specific program]___ [Name of specific program]___ [Name of specific program]If you marked any or all of the programs listed above, fill out the form below. I understand that I am releasing information (student’s name, F/R status, and/or contact information) to only the programs I have marked. I certify that I am the parent/legal guardian of the child(ren) for whom application is being made.Signature of Parent/Guardian: __________________________________Date: _______________Printed Name: _____________________________________________________________________Address: _________________________________________________________________________Child’s Name: _________________________________School: ______________________________Child’s Name: __________________________________School: _____________________________Child’s Name: __________________________________School: _____________________________For more information, call [add district contact information].Return this form to: [address] by [date]This institution is an equal opportunity provider. ................
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